Effectiveness of a Nurse-Based Outreach Program for Identifying and
Treating Psychiatric Illness in the Elderly

Author Affiliations: Departments of Psychiatry and Behavioral Sciences (Drs Rabins and Black and Mss Robbins and Rye) and Medicine (Drs Rabins and German), School of Medicine, and Departments of Health Policy and Management (Drs Rabins and German) and Mental Hygiene (Dr Rabins), School of Hygiene and Public Health, Johns Hopkins Medical Institutions, Sheppard and Enoch Pratt Hospital (Drs Roca and McGuire), and Gerontology Research Center, National Institute on Aging (Dr Brant), Baltimore, Md.

Context Elderly persons with psychiatric disorders are less likely than younger
adults to be diagnosed as having a mental disorder and receive needed mental
health treatment. Lack of access to care is 1 possible cause of this disparity.

Objective To determine whether a nurse-based mobile outreach program to seriously
mentally ill elderly persons is more effective than usual care in diminishing
levels of depression, psychiatric symptoms, and undesirable moves (eg, nursing
home placement, eviction, board and care placement).

Design Prospective randomized trial conducted between March 1993 and April
1996 to assess the effectiveness of the Psychogeriatric Assessment and Treatment
in City Housing (PATCH) program.

Setting Six urban public housing sites for elderly persons in Baltimore, Md.

Participants A total of 945 (83%) of 1195 residents in the 6 sites underwent screening
for psychiatric illness. Among those screened, 342 screened positive and 603
screened negative. All screen-positive subjects aged 60 years and older (n=310)
and a 10% random sample of screen-negative subjects aged 60 years and older
(n=61) were selected for a structured psychiatric interview. Eleven subjects
moved or died; 245 (82%) of those who screened positive and 53 (88%) of those
who screened negative were evaluated to determine who had a psychiatric disorder.
Data were weighted to estimate the prevalence of psychiatric disorders at
the 6 sites.

Intervention Among the 6 sites, residents in 3 buildings were randomized to receive
the PATCH model intervention, which included educating building staff to be
case finders, performing assessment in residents' apartments, and providing
care when indicated; and residents in the remaining 3 buildings were randomized
to receive usual care (comparison group).

Main Outcome Measures Number of undesirable moves and scores on the Montgomery-Asberg Depression
Rating Scale (MADRS), a measure of depressive symptoms, and the Brief Psychiatric
Rating Scale (BPRS), a measure of psychiatric symptoms and behavioral disorder,
in intervention vs comparison sites.

Conclusions These results indicate that the PATCH intervention was more effective
than usual care in reducing psychiatric symptoms in persons with psychiatric
disorders and those with elevated levels of psychiatric symptoms.

Elderly adults with psychiatric disorders are less likely to be diagnosed
as having a mental disorder or to receive needed mental health treatment than
younger adults.1,2 This unmet
need is likely due to factors such as underrecognition by providers; transportation
and access difficulties; reluctance of practitioners to diagnose psychiatric
disorder; reluctance of the elderly to accept the diagnosis of a psychiatric
illness; difficulties disentangling coexisting medical, psychiatric, and social
morbidity; and the 50% copay requirement for mental health services under
current Medicare legislation.3- 6
No single solution is likely to address these many issues, but earlier recognition
of disorder and improved delivery of services are 2 approaches that may reduce
unmet need.7,8

One program developed to address lack of access to care is the Assertive
Community Treatment model, which relies on mobile treatment teams and has
well-established efficacy in young and middle-aged adults.9- 11
Another innovative model, the Gatekeeper approach12
seeks to increase the likelihood that elderly persons with potential psychiatric
disorders are identified and referred to mental health service for assessment
by training people who work in the community, such as bank tellers, mail carriers,
and meter readers. Its innovation is the use of these community workers as
"case finders."

This study prospectively examines the effectiveness of a treatment model
that combines principles of the Assertive Community Treatment and Gatekeeper
models. This program, entitled Psychogeriatric Assessment and Treatment in
City Housing (PATCH), targets elderly persons living in urban public housing
developments.13 The PATCH intervention model
has 3 elements: (1) the training of indigenous building workers, such as managers,
social workers, groundskeepers, and janitors, to identify those at risk for
psychiatric disorder; (2) the identification and subsequent referral of potential
cases by these workers to a psychiatric nurse; and (3) psychiatric evaluation
and treatment in the residents' homes. Psychiatric nurses are the primary
service providers, with psychiatrists serving as supervisors or consultants.
This study was designed to determine whether the PATCH program could reduce
psychiatric symptoms among elderly residents needing care and enable them
to remain in public housing. This population was chosen because rates of psychiatric
disorder among elderly public housing residents are 50% higher than matched
individuals living in the community14- 16
and because this psychiatric morbidity predisposes residents to adverse outcomes
such as eviction and termination of lease.17,18
We have previously reported that 26.9% of residents of public housing for
the elderly in Baltimore, Md, had a psychiatric disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, Revised
Third Edition (DSM-III-R) (Table 1) and that 58% of those meeting criteria for needing mental
health care are receiving no treatment.19,20

METHODS

Six public housing developments for the elderly in Baltimore, Md, served
as study sites. Each was a large urban apartment building that provided no
on-site psychiatric care. The study was approved by the institutional review
board of the Johns Hopkins School of Medicine and was conducted between 1992
and 1996.

Initially, a baseline epidemiological survey was conducted at the 6
sites to determine rates of DSM-III-R psychiatric
disorder and to measure levels of psychiatric symptoms. Next, a randomization
procedure was performed. Three matched pairs of study sites were established
by identifying the buildings that most resembled each other on demographic
characteristics and number of residents. Within each pair, a coin flip determined
whether a building was designated an intervention site or a comparison site.
Residents of the 3 intervention sites and 3 comparison sites constituted the
study population, with the unit of analysis being the 3 intervention vs the
3 comparison sites. Following the intervention phase, a final epidemiological
survey was conducted at all 6 sites to determine final symptom levels. Effectiveness
of the PATCH model was determined by comparing baseline and final symptom
scores of those with a psychiatric disorder at baseline and the likelihood
of residents making "undesirable moves." Figure 1 shows the flow of subjects through the 3 phases of the
study.

All 1195 residents were sent a letter explaining the study. However,
before each resident was contacted by a research assistant who explained the
study and sought informed consent, 17 residents had moved away or had died.
Eighty percent (n=945) of the remaining 1178 residents agreed to participate
and gave informed consent orally. For potential subjects who had a cognitive
impairment severe enough to impair capacity to consent, a proxy was identified
by that subject and his/her consent was also sought. All subjects were informed
that some buildings would not be offered PATCH services but that residents
of these buildings could seek usual care.

A 2-stage case finding approach was used in the baseline and final epidemiological
surveys. In stage 1, each subject was administered a set of demographic questions
and 3 screening instruments, the General Health Questionnaire21
to screen for emotional symptoms, the Mini-Mental State Examination22 to screen for cognitive disorders, and the CAGE questionnaire23 to screen for alcohol use disorder. Individuals were
identified as having a clinically significant level of psychiatric symptoms
requiring further assessment if they scored 5 or more on the General Health
Questionnaire, 17 or less on the Mini-Mental State Examination, or a score
of 2 or more on the CAGE questionnaire. Subjects who met these criteria were
categorized as screen-positive, and those who did not meet these criteria
were categorized as screen-negative. Thirty-six percent of the baseline stage
1 participants screened positive.

All subjects aged 60 years and older who screened positive and a 10%
random sample of those who screened negative were selected for stage 2 of
the baseline survey in which participants were administered the Structured
Clinical Interview for DSM-III-R24
and a cognition assessment based on DSM-III-R criteria
for cognitive disorder that was developed for this study. Eleven of the 371
residents selected to participate at stage 2 moved or died before the initial
contact. Two hundred forty-five (82%) of those who screened positive and 53
(88%) of those who screened negative (overall 83% of the 360 asked to participate)
agreed to participate. The Structured Clinical Interview for DSM-III-R was administered by trained mental health professionals who
were blinded to the screening status of the subjects. The data from stage
2 were used to identify subjects with a psychiatric disorder and estimate
the prevalence of psychiatric disorders.16
The randomization and intervention took place after stage 2 was completed.

The PATCH intervention model was provided in the 3 intervention sites
in the following manner:

The PATCH nurse met with building management staff to introduce and
discuss the outreach program.

A structured education program (available
on request) was provided to enable building staff to recognize and refer residents
needing mental health care. It consisted of seven 1-hour presentations on
normal and pathological aging, mood disorder, schizophrenia, substance abuse,
dementia, the emergency petition process, and issues related to death and
dying. During this phase of the intervention the nurse also spoke to the tenant
council, a monthly governance meeting residents attend voluntarily.

Thereafter, the nurse visited each site
weekly to receive referrals for residents who may have been at risk for psychiatric
disorder and to provide services. PATCH nurses and building staff were blinded
to the prevalence of mental morbidity at each study site and to the identity
of subjects determined to have a psychiatric disorder during the baseline
epidemiological survey.

Residents referred were contacted by telephone
(if they had one) or by mail, told that someone had expressed concern about
them, and offered an evaluation. Each resident who was referred and agreed
to have an evaluation was assessed by the nurse in his/her apartment. Subsequently,
the nurse presented the case to the psychiatrist, and they conducted a joint
inhome clinical examination. Based on the evaluation, the psychiatrist and
nurse developed a treatment plan for each resident who needed care and offered
this plan to the resident.

A concomitant study of the PATCH nurses' daily activities was conducted
to illustrate the types of interventions provided after a resident's in-home
assessment and clinical examination. Table
2 lists the services most frequently provided by 3 nurses during
four 1-month periods. On average, patients were seen 5 times. Most initial
assessments took approximately 1 hour and follow-up contacts averaged 30 minutes.
The 2 most frequent interventions were counseling patients and providing patient
education about their illness and positive health behaviors. Four of the 10
interventions involved ensuring that patients obtain and use medications appropriately.

Each month during the study, a research assistant visited the 6 housing
sites and obtained information on individuals who had moved to another setting
or had died. The intervention ended at 26 months and a second 2-stage epidemiological
survey was conducted. The final screening interview was readministered to
all the residents of the 6 buildings who had participated at baseline stage
1 and again gave consent to participate in the final stage 1 survey. The final
stage 2 interview (Structured Clinical Interview for DSM-III-R and cognitive assessment) was administered to all final stage 1 subjects
who screened positive, a 10% random sample of those who screened negative,
and any other residents, not otherwise selected from those who participated
in the baseline stage 2 survey. This sampling approach enabled us to maximize
the number of baseline survey participants on whom complete outcome data were
available. Participants in both the baseline and final surveys were reimbursed
for their time: $3 to $5 for stage 1 participants, $10 for stage 2 participants
in the baseline survey, and $15 for stage 2 participants in the final survey.

During both the baseline and final epidemiological surveys, interviewers
who found a resident at any of the 6 study sites to be in urgent need of care
consulted with 1 of the study's psychiatrists (P.V.R., R.R., or M.M.) by telephone
and referred the subject to an appropriate provider. Following completion
of the final epidemiological survey, the PATCH program was implemented at
the 3 comparison sites.

There were 3 primary outcome measures: the Brief Psychiatric Rating
Scale (BPRS)25,26 to measure psychiatric
symptoms and behavioral disorders; the Montgomery-Asberg Depression Rating
Scale (MADRS)27,28 to detect change
in mood and to measure depressive symptoms. These were administered during
stage 2 of both the baseline and final surveys. The third outcome, a composite
measure entitled undesirable moves, included subjects who were evicted or
who moved from the building to a nursing home or to a board-and-care home
during the study. Undesirable moves did not include moving to live with family
members since this is considered a positive outcome by many residents.

We hypothesized before the study that persons identified as having a DSM-III-R defined psychiatric disorder at baseline and
residing in the active treatment sites at follow-up would have lower psychiatric
symptom scores and fewer undesirable moves at follow-up than residents with
a psychiatric disorder living in the nonintervention comparison sites. We
did not hypothesize that rates of disorder would decline, because most of
the prevalent disorders in this population (cognitive impairment with behavior
disorder, mood disorder, schizophrenia, and substance abuse) are chronic conditions.16

To determine whether a broader definition of need
for treatment would result in findings similar to those for subjects
with a psychiatric disorder, post hoc analyses were conducted using data from
those identified as needing mental health care.19
This secondary definition of needing treatment was based on any of the 3 criteria:
(1) having a psychiatric disorder identified by the Structured Clinical Interview
for DSM-III-R or having a cognitive disorder and
a BPRS score above the mean (thus defining individuals with both a cognitive
disorder and significant noncognitive psychiatric symptoms), (2) having moderate
or severe emotional distress (General Health Questionnaire score ≥5), or
(3) reporting poor or very bad self-rated mental health.

Descriptive and bivariate statistics were used to characterize the stage
1 participants and the psychiatric cases identified at stage 2 of the baseline
survey. The sampling approach used at stage 2 minimized cost but necessitated
weighting the stage 2 data to make inferences about the larger stage 1 sample.
Stage 2 data were weighted to account for the sampling procedure used to select
subjects who screened negative and the differing stage 2 response rates of
the screen-positive and screen-negative subjects. The data for subjects who
screened negative were weighted to adjust for both the 10% random sampling
procedure and their stage 2 response rate of 88%. Since all subjects who screened
positive were selected for interviewing at stage 2, their data were weighted
to adjust for only their stage 2 response rate of 82%. Weighted data from
subjects who were present at both the baseline and final epidemiological surveys
were used in the analysis of the BPRS and MADRS scores, the repeated-measures
analysis of variances and multiple regression analyses to determine significance
of score changes. Unweighted data on these subjects were used in the Cox regression
analysis of undesirable moves since weighted data cannot be used in this procedure.
Data on those who moved into the study sites after the baseline survey was
completed are excluded from these analyses.

RESULTS

Table 3 presents demographic
and descriptive data at baseline for all stage 1 subjects. The sample is made
up of predominantly black persons and women. Most subjects lived alone. Subjects
residing in the intervention and nonintervention sites were comparable except
for higher mean education, fewer people with incomes below the poverty level,
and fewer black persons among those living in the intervention sites.

At baseline, there was no significant difference (χ21=2.74, P=.10) in the prevalence of psychiatric
disorders between the comparison sites (24%) and intervention sites (29%)
and no difference (χ21=0.18, P=.67) between these sites (36% vs 38%) based on the broader definition
of needing mental health care. Table 4
compares psychiatric cases in the intervention and comparison buildings at
baseline. Subjects with a psychiatric disorder residing in the comparison
sites included a greater proportion of men and people who had never married.
Thirty-five percent of subjects with a psychiatric disorder and 43% of subjects
needing mental health treatment reported having received mental health care
from either their medical provider or a mental health professional in the
previous 6 months.

Table 5 presents baseline
and 26-month follow-up scores on the BPRS and MADRS in the intervention and
comparison groups. It presents weighted data on subjects defined as having
a psychiatric disorder and subjects defined more broadly as needing mental
health care who were living in the buildings at the beginning and end of the
study. There were no significant differences at baseline between mean scores
for the intervention and comparison sites, although repeated-measures analysis
of variances demonstrate that subjects had lower BPRS and MADRS scores in
the treatment group at the end of the study. Subjects without a need for psychiatric
treatment did not show significant differences in BPRS (F1=1.74, P=.19) or MADRS (F1=3.48, P=.06) scores.

Further analyses demonstrated that the intervention remained a significant
factor after controlling for subjects receiving mental health treatment at
baseline (among those with a psychiatric disorder, BPRS F2=3.56, P=.032; MADRS F2=13.0, P<.001;
among those needing care, BPRS F2=4.1, P=.018;
MADRS F2=11.5, P<.001). To assess whether
certain diagnostic groups had more positive outcomes, we categorized diagnoses
into 3 groups: mood disorder (depression plus anxiety), psychotic disorder
(schizophreniform disorders plus cognitive impairment with behavioral disorder),
and substance abuse, and examined their change in BPRS and MADRS scores. In
stepwise multiple regression analyses, only the mood disorder group showed
significant improvement in MADRS scores (F1=17.6, P<.001). The decline in BPRS scores was attributable only to subjects
without a psychotic disorder (F1=4.5, P=.04).

Nine percent of the baseline stage 2 subjects (n=28) had died by the
end of the study and 12% (n=37) had made desirable moves to either a private
home or apartment, to another public housing building that was not one of
the study sites, or in with family. There was no difference between the intervention
and comparison sites in the proportion of residents with desirable moves (χ21=.05, P=.82) although subjects
at intervention sites were more likely to die (χ21=5.18, P=.02) than those at the comparison sites (14% vs 6%).
Three of the stage 2 subjects, all of whom were residents of the comparison
buildings, reported psychiatric hospitalizations. Eleven percent of stage
2 subjects had made undesirable moves to either a nursing home or to a board-and-care
home, and none were evicted. A Cox proportional hazard regression analysis
found no difference in undesirable moves between the treatment and comparison
sites (β=−.03, SE=.41, df=1, P=.95); (relative risk [RR], 0.97; 95% confidence interval [CI], 0.44-2.17).
A log-minus-log survival plot showed that the data met the assumption of proportionality;
no time-dependent variable was included in the model. Sixty-six percent of
subjects in the comparison sites with psychiatric disorders reported receiving
mental health treatment during the trial.

COMMENT

These results demonstrate that a model of care that uses indigenous
workers as case finders and a mobile treatment team staffed by psychiatric
nurses can decrease levels of psychiatric symptoms in elderly persons with
psychiatric disorders who reside in a high-risk setting. The PATCH intervention
consisted of several elements: the education and use of indigenous case finders
who encounter members of the target population on a daily basis; a reliance
on psychiatric nurses to provide assessment, guide treatment, and provide
case management services; and the initial provision of services in the patient's
apartment. We believe the model's effectiveness rests on the improved case
recognition provided by the case finder model and better treatment adherence
resulting from on-site treatment by the nurse. Whether any of these elements
would have been effective by itself can only be determined by further study.
As this is one of only a handful of population-based interventions that demonstrate
the effectiveness of psychiatric assessment and treatment in the elderly,29- 31 replication and adaptation
to other high-risk settings and other populations would be of interest.

The declines in symptom scores (17% in BPRS scores, 32% in MADRS scores)
among subjects in the treatment sites are comparable to those reported in
efficacy studies and are clinically meaningful. The use of rating scales rather
than case criteria as outcomes allowed us to demonstrate an impact on the
target population rather than on individual subjects. However, the intervention
did not prevent placement of residents into nursing homes or to board-and-care
facilities, perhaps because such placement was recommended when an individual
was deemed unsafe to live alone.

The 2-stage epidemiological case finding method used in this study has
not been widely used in intervention trials. This approach provides an efficient
means of identifying individuals in the population with target disorders and
provides a random sample of persons who do not have psychiatric symptoms.
This method requires weighting back to the stage 1 sample and can be criticized
as artificially increasing sample size and power. However, we believe it is
a useful strategy for studying interventions in which the unit of analysis
is a population and the targets of the intervention are persons with a disorder.
It is a practical and cost-effective method that might be used in other treatment
trials that target individuals who meet the study criteria.32,33

This study illustrates several of the challenges faced by effectiveness
studies of models of care.32- 35
One significant limitation is the lack of a single standardized treatment
as the independent variable. The education intervention did follow a specific
format, but the clinical intervention could not be formalized because it targeted
individuals with any DSM-III-R disorder and because
many subjects had coexisting medical and social morbidities that also required
treatment. In contrast, effectiveness studies of single treatments for specific
disorders can apply a standard approach to all subjects in the active treatment
group.29- 31,36
This study is best viewed as a test of how care is delivered rather than an
assessment of what specific services are being delivered.

The criterion for having psychiatric illness in this study was defined
a priori as having any disorder identified by the Structured Clinical Interview
for DSM-III-R or having a cognitive disorder. Post
hoc analyses demonstrated that a broader definition of needing mental health
care was also associated with a positive outcome. Although the identification
of those in need of mental health care is complex,19,37
these results suggest that the PATCH model is effective whether a narrow or
broad definition of need for treatment is used.

The use of a nontreated comparison group raises appropriate questions
about the ethical use of a nontreatment group.38
In this study, the nontreatment group could receive usual care and two thirds
did receive care. Nevertheless, individuals were identified in both the active-treatment
and comparison buildings who had a potentially treatable psychiatric disorder
and were not informed of this. We believe this is ethically justifiable because
the model being tested had not been studied before and therefore its effectiveness
was unknown.39 Subjects with severe symptoms
of depression, psychosis, hypotension or bradycardia identified during screening
or the Structured Clinical Interview for DSM III-R
were referred for immediate care whether in an intervention or comparison
site. Fewer than 10 individuals required such a referral. PATCH services were
made available to all building sites at the completion of the study.

Current Medicare policy reimburses home care only for persons who are
homebound. The results presented herein demonstrate that persons who have
a serious and persistent mental illness and have not had their needs met in
traditional office settings can benefit from home-based evaluation and treatment.
They support an extension of the Medicare home care benefit to cover home
mental health care for the following individuals: those who would otherwise
not be treated; those who would come to treatment later and suffer adverse
effects (such as eviction); those whose untreated psychiatric disorders would
cause significant distress to them, their family members, their caregivers,
or their neighbors; and those at high risk of institutionalization. The 100-year
tradition of public health nursing remains the ideal model for such care.40- 44